Around 10 % of the global adult population has active migraine. The public health burden of migraine is high because migraine attacks are associated with temporary disability and substantial impairment in activities. As such, migraine is ranked as one of the most disabling conditions. The widespread disability produced by migraine is therefore an important target for treatment.

The hallmark of migraine is the head pain, but a plethora of other clinical symptoms is needed for a headache to be qualified as a migraine according to the current diagnostic criteria.

There has been tremendous progress in our acceptance, understanding and treatment possibilities of migraine, but to optimize migraine management, it is important that we continue to improve our understanding of the basic migraine mechanisms. An understanding of migraine pathophysiology must encompass the varied clinical symptoms and relate these findings to anatomy and physiology.

The headache research field is privileged to have in its preclinical laboratories well-established animal models that significantly facilitate and improve our understanding of headache mechanisms, in particular in terms of the molecular signalling and brain networks involved. A variety of pharmacological screening approaches for novel therapeutics and for the improvement of advanced pharmacological agents can be achieved in translational research utilising these models. The available migraine models have been developed based on our understanding of migraine from clinical, migraine patient-specific evidence. These clinical phenotypes have been successfully employed to model features of the disease physiology in animals and to provide reproducible meaningful physiological measures in the laboratory.

Multiple observational studies have identified a link between patent foramen ovale (PFO) and migraine headache. PFO is found in 40 to 60 % of people who have migraine with aura compared to 20 to 30 % in the general adult population. It is hypothesized that migraine, especially migraine with aura or other transient neurologic deficits, may be triggered by chemicals that are ordinarily metabolized during passage through the lungs. However, the presence of a right-to-left shunt allows these chemicals to bypass metabolic alteration in the lungs and gain entry to the arterial circulation in a higher concentration so that upon reaching the brain, they stimulate receptors in susceptible individuals which produces the cerebral migraine phenomena. This hypothesis was derived after observations that PFO closure for other reasons, such as decompression sickness in divers or to prevent cryptogenic stroke, resulted in relief of migraine headaches. Although migraine is not currently an indication for PFO closure, the possible benefit of percutaneous PFO closure as a treatment for migraine headache will be revealed as results from further prospective randomized trials become available.

Migraine is a common disabling neurological disorder resulting from excessive cortical excitation and trigeminovascular afferent sensitization. In addition to aberrant neuronal processing, migraineurs are also at significant risk of vascular disease. Consequently, the impact of migraine extends well beyond the ictal headache and includes a well-documented association with acute ischemic stroke, particularly in young women with a history of migraine with aura. The association between migraine and stroke has been acknowledged for 40 years or more. However, examining the pathobiology of this association has become a more recent and critically important undertaking. The diversity of mechanisms underlying the association between migraine and stroke likely reflects the heterogenous nature of this disorder. Vasospasm, endothelial injury, platelet aggregation and prothrombotic states, cortical spreading depression, carotid dissection, genetic variants, and traditional vascular risk factors have been offered as putative mechanisms involved in migraine-related stroke risk. Assimilating these seemingly divergent pathomechanisms into a cogent understanding of migraine-related stroke will inform future studies and the development of new strategies for the prevention and treatment of migraine and stroke.

Migraine is a common cause of vestibular discomforts. Vestibular symptoms should be considered as equivalents to the commonly known migraine symptoms, such as visual aura, photophobia, phonophobia, nausea, and headaches and are among the cardinal presentations of migraine in many patients. Those vestibular symptoms reflect the impaired perception of a normal or physiological spatial orientation and head motion. The subject’s vestibular system becomes unusually susceptible and over-reactive. To be diagnosed with vestibular migraine, the patient must have both unequivocal vestibular symptoms and a history of migraine. In addition, a temporal correlation between those vestibular symptoms and the migraine history must exist and alternative causes excluded. A few clinical vertiginous conditions have significant overlaps with migraine in their clinical presentations and may also share similarities in their pathologies. Those conditions must be recognized and differentiated from each other. Recent international efforts have resulted in newly proposed criteria for diagnosing vestibular migraine. These criteria can be used as references in the clinical reasoning toward diagnosing this common neurological disorder.

Opinion statement

The diagnosis of migraine in the pediatric population is increasing as providers are becoming more familiar with recognizing the condition. Over-the-counter and migraine-specific treatment, once considered off-label, have proven to be effective, especially if given at the early onset of head pain. Mild to severe cases of migraine should be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), with triptans used alone or in combination in moderate to severe headaches unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine (DHE), a potent vasoconstrictor should be used for intractable migraines and is preferred in the hospital setting. Anti-emetics that have anti-dopaminergic properties can be helpful in patients with associated symptoms of nausea and vomiting along with headache, especially when used in combination therapy. Preventative treatment should be initiated early in patients with frequent headaches to improve headache outcomes and quality of life. Patients and families should be educated on non-pharmacologic management, such as lifestyle modification and avoidance of triggers, that can prevent progression and worsening of migraine.

Primary headaches consist of migraine, tension-type headaches, and trigeminal autonomic cephalalgias (e.g., cluster headache). Migraine and tension-type headaches are common and, in chronic form, are major causes of disability. Prospective double-blind and placebo-controlled studies have confirmed the efficacy of onabotulinumtoxinA (onaA) in chronic migraine (class A evidence). Follow-up of patients in PREEMPT studies with five cycles of onaA injections (over 56 weeks) attests to the tolerability and safety of this drug in chronic migraine and demonstrates progressive improvement of patient’s quality of life. In clinical practice, patients treated with onaA for more than 2 years describe their experience as very gratifying (attached videotapes). Studies using onaA in management of episodic migraine and chronic daily headaches have shown disappointing results and no evidence of efficacy. Investigations using botulinum neurotoxins (BoNTs) in management of tension-type headache have also provided negative results, but the results are confounded by selection of low-dose, suboptimal technique and selection of rigid primary outcome criteria. No blinded studies with BoNTs are available for trigeminal autonomic cephalalgias.

Background

Studies of the difference between menstrually associated and non-menstrually associated migraine are somewhat controversial. The majority of studies have focused on comparing menstrual to non-menstrual attacks rather than comparing study groups with different migraine diagnoses with respect to menstruation. As there is limited knowledge available on the overall impact and burden of migraine among groups of women with and without menstrually associated migraine our goal was to examine differences between these groups. We hypothesized that there would be greater burden of migraine related to menstruation and headache frequency in a population study across groups of women.

Methods

We analyzed data from the American Migraine Prevalence and Prevention (AMPP) Study, a longitudinal, US, population-based study. We included female respondents to the 2009 survey, aged 18 to 60, who met modified ICHD-2 criteria for migraine, were actively menstruating and fit one of three definitions based on the self-reported association of menses and migraine attacks: self-reported predominantly menstrual migraine (MM, attacks that only or predominantly occur at the time of menses), self-reported menstrually-associated migraine (MAM, attacks commonly associated with menses, but that also occur at other times of the month), and self-reported menstrually-unrelated migraine (MUM). These three groups were compared on characteristics and measures of headache impact and burden (Headache Impact Test– 6 item (HIT-6) and Migraine Disability Assessment Scale (MIDAS).

Results

There were 1,697 eligible subjects for this study in the following categories: MM (5.5%), MAM (53.8%), or MUM (40.7%). Women with MM had an older age of migraine onset. Those with predominantly menstrually-related attacks (MM) had fewer headache-days but appeared to be more impaired by attacks. HIT-6 and MIDAS scores were significantly higher for both the MM and MAM groups compared with the MUM groups; however, effects were more robust for MM than MAM.

Conclusions

Nearly 60% of women with migraine reported an association between migraine and menses. These women reported greater headache impact and migraine-related burden on functioning than those in whom migraines were not related to menstruation. Women with MM were more impaired by attacks while women with MAM had overall highest burden, likely due to experiencing migraines on additional days.

Background

Randomized clinical trials have demonstrated that the efficacy of a fixed-dose single-tablet combination containing sumatriptan and naproxen sodium (S/NS) was greater than either of its individual components. Simplifying drug regimens (e.g., via a fixed-dose combination) has been shown to improve “real-world” outcomes by reducing pill burden and treatment regimen complexity, improving adherence, and reducing healthcare resource use and associated costs; however, no studies assessing such outcomes have been conducted to date for the acute treatment of migraine.

Objective

To assess migraine-related healthcare resource use and associated costs for subjects prescribed S/NS vs. subjects prescribed single-entity oral triptans (SOTs) within a managed care population in the USA.

Methods

In this retrospective analysis of administrative claims data from July 1, 2008 to December 31, 2009 (IMS LifeLink), subjects meeting the following criteria were selected: one or more pharmacy claim(s) for either S/NS or SOT (index date), aged 18–64 years; at least one migraine diagnosis, and continuous enrollment in the 6 months prior to and post the index date. The study population was subsequently stratified for two analyses: triptan-naïve (triptan naïve in the 6-month period prior to the index date) and triptan-switch (triptan user in the 6-month period prior to the index date and switching to another triptan). Subjects prescribed S/NS were propensity-score matched with subjects prescribed SOT (triptan-naïve analysis: 1:3; triptan-switch analysis: 1:1) to assess differences in healthcare resource use and associated costs (2009 US$) between the S/NS and SOT groups.

Conclusion

Study results suggest similar healthcare resource use patterns and associated costs when comparing S/NS and SOT across a triptan-naïve and triptan-experienced population. While the current study focuses on direct medical costs, future studies should extend beyond such a perspective to explore functional status, productivity, and health-related quality of life and satisfaction, attributes not captured in administrative claims data, but nonetheless important treatment goals.

Migraine is a frequently disabling disorder which may require inpatient treatment. Admission criteria for migraine include intractable migraine, nausea and/or vomiting, severe disability, and dependence on opioids or barbiturates. The inpatient treatment of migraine is based on observational studies and expert opinion rather than placebo-controlled trials. Well-established inpatient treatments for migraine include dihydroergotamine, neuroleptics/antiemetics, lidocaine, intravenous aspirin, and non-pharmacologic treatment such as cognitive–behavioral therapy. Short-acting treatments possibly associated with medication overuse, such as triptans, opioids, or barbiturate-containing compounds, are generally avoided. While the majority of persons with migraine are admitted on an emergency basis for only a few days, outcome studies and infusion protocols during elective admissions at tertiary headache centers suggest a longer length of stay may be needed for persons with intractable migraine.